Form PQ

Personal Questionnaire

PERSONAL QUESTIONNAIRE IN RESPECT OF DIRECTORS OF COLLECTIVE INVESTMENT SCHEMES MANAGER
FULL NAME OF MANAGER:
FULL NAME OF PERSON COMPLETING APPLICATION:
CONTACT DETAILS OF PERSON COMPLETING THE APPLICATION:
telephone: email:
Please send the completed form, supporting documents and prescribed fee (see the Financial Services Board Fees available on the Board’s website) to the address below.
Financial Services Board
Riverwalk Office Park
Block B
41 Matroosberg Road
Ashlea Gardens, Extension 6
Pretoria
0181
South Africa / Telephone: 012428 8000
Website:
  1. PERSONALDETAILS

Title (Mr/Mrs/Msetc.):
Surname:
Forenames (In full)
Also Known as (if applicable)
Date of birth (yy/mm/dd)
Have you ever changed your name / YES / NO
Reason for Change
Previous Full Names & title / Date Changed / Registry at which details are recorded

2.RESIDENCE

Current private address and date from(mm/yy):
Allotherprivateaddress(es)in the previousfiveyearsand dates(month and year):
NOTE:Ifmorespaceisneededtheanswersshouldbewrittenonaseparatesignedanddatedsheetofpaperand referenced to thisquestion.
Address: / From(mm/yy) / To (mm/yy)
Address: / From(mm/yy) / To (mm/yy)
Address: / From(mm/yy) / To (mm/yy)

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Form PQ

Personal Questionnaire

  1. EMPLOYMENT

3.1.CurrentEmployment

Job Title:
Period ofemployment
[Startdate - mm/yy]:
Nameofpresent/proposed employer:
Addressofpresent/proposed employer:
Nature ofpresent/proposed employer’sbusiness:
Nameofanygroup companiesorrelatedcompaniesofyouremployer/proposed employerforwhomyou actasa Director,PartnerorController:
Job description(s)and responsibilities:

3.1.1.Indicate whether in your position as director you have or will have executive responsibility for the management of the manager’s business: If so, furnishparticulars:

3.1.2.In carrying out your duties, will you be acting on the directions or instructions of any other individual or body corporate? If so, furnish particulars:

3.1.3.If you are being appointed as an independent non-executive director:

YES / NO
  1. Are you or will you be a director who is a representative of a shareholder, partner or similar who has the ability to control or significantly influence management of the manager?

  1. Have you been employed by the manager, or any company in the group, of which it currently forms part, in an executive capacity?

  1. Are you a member of the immediate family of any individual who is, or has during the preceding three financial years, been employed by the manager or any group company in an executive capacity?

  1. Are you a professional advisor to the manager or any company, other than in a director’s capacity?

  1. Do you have any business or other relationship (contractual or statutory) which could be seen by an objective outsider to interfere materially with your capacity to act in an independent manner, such as being a director of a material customer of or supplier to the manager?

  1. Do you receive remuneration contingent upon the performance of the manager?

If the answer is “yes” to any of the questions in the table above, specify the matters that affect or may affect your independence. If necessary, use a separate appendix (clearly annotated and referenced to this section) and attach it to this application.

Schedule Reference:

3.1.4Are you a director of, or do you have a direct or indirect interest inor are you associated with any other collective investment schemeor any other party related to the administration of a collectiveinvestment scheme (e.g. authorised agent, administrator, investment manager, etc.):

Y / N

If the answer is “Yes”, provide detail. If necessary, use a separateappendix (clearly annotated and referenced to this section) and attachit to this application.

Schedule Reference:

3.2. List of any other body corporate in which you have a direct or indirect interest presenting 15% or more of the issued capital of that body corporate.

Name of organization / Nature of business / % Interest / Date of holding
From / to
  1. PREVIOUS EMPLOYMENT

Listall appointmentsand positionsyou have held overthe last10years.

If morespaceis needed the answersshould bewritten on a separatesigned and datedsheetof paper and referenced to thisquestion.

Name of Employer / Position held / Designation / Datecommenced ceased –[mm/yy] / Principle responsibilities
  1. Business relationships in respect of individual proposing to become a director
  2. Does any of the employers/organisations/body corporate listed in reply to questions 4 maintain a businessrelationship with the manager?

Y / N

If the answer is “Yes”, provide detail:

Schedule Reference:

5.2Do you carry on, or have you ever carried on, or applied for any licence or equivalent authorisation to carry on any business activity in the RSA or elsewhere?

Y / N

If the answer is “Yes”, provide detail:

Schedule Reference:

5.3Has any application referred to in paragraph 5.2 above been refused or withdrawn after it was granted or any registration revoked?

Y / N

If the answer is “Yes”, provide detail:

Schedule Reference:

5.4Do you, in your private capacity, or does any associate of yours, undertake business with the manager?

Y / N

If the answer is “Yes”, provide detail:

5.5Does any institution with which you are, or have been, associated as a director or managing executive hold, or has it ever held or applied for a licence or equivalent authorisation to carry on any related business activity?

Y / N

If the answer is “Yes”, provide detail:

5.6Was any application referred to in paragraph 5.5 refused or withdrawn after it was granted or any registration revoked?

Y / N

If the answer is “Yes”, provide detail:

  1. Disciplinary matters in respect of individual proposing to become a director.

6.1.Fit and proper requirements for directors:

6.1.1.Has an adverse finding been made against you within a period of five years preceding the date of application in any civil or criminal proceedings by a court of law (whether in the Republic of South Africa or elsewhere) in which you were found tohave acted fraudulently, dishonestly, unprofessionally, dishonourably or in breach of a fiduciary duty?

Y / N

If the answer is “Yes”, provide detail:

6.1.2.Have you within a period of five years preceding the date of application been found guilty by any professional or financial services industry body (whether in Republic or elsewhere), of an act of dishonesty, negligence, incompetence or mismanagement?

Y / N

If the answer is “Yes”, provide detail:

6.1.3.Have you within a period of five years preceding the date of application been denied membership of any body referred to in paragraph 6.1.2 on account of an act of dishonesty, negligence, incompetence or mismanagement?

Y / N

If the answer is “Yes”, provide detail:

6.1.4.Have you within a period of five years preceding the dateof application been found guilty by any regulator or supervisory body (whether in the Republic or elsewhere), or has an authorisation to carry on business been refused, suspended or withdrawn by any such body on account or an act of dishonesty, negligence, incompetence or mismanagement?

Y / N

If the answer is “Yes”, provide detail:

6.1.5.Have you within a period of five years preceding the date of this application, or appointment as director, as the case may be, had any authorisation by any regulatory or supervisory body referred to in paragraph 6.1.4 suspended or withdrawn by suchbody on account of an act of dishonesty, negligence, incompetence or mismanagement, sufficiently serious to impugn the honesty and integrity of you as director?

Y / N

If the answer is “Yes”, provide detail:

6.1.6.Have you at any time prior to the date of applicationbeen disqualified or prohibited by any court of law (whether in the Republic or elsewhere) from taking part in the management of any company or other statutorily created, recognised or regulated body, irrespective whether such disqualification has since been lifted or not?

Y / N

If the answer is “Yes”, provide detail:

6.2.Additional Information

6.2.1.Have you at any time been convicted of any offence, other than –

(a)any offence already mentioned in paragraph 6.1;

(b)any offence committed when you were under18 years,unless the same was committed within the previous 10 years;

(c)any road traffic offence in respect of which a fine was levied; or

(d)any political offence for which amnestyhas been granted?

Y / N

If the answer is “Yes”, furnish particulars of the court by which you were convicted, the offence, the penalty imposed and the date of conviction:

6.2.2.Have you been refused the right to carry on or restricted from carryingon a trade, business orprofession for which a specific licence, registration or other authority is required by law in any country?

Y / N

If the answer is “Yes”, provide detail:

6.2.3.Have you been issued with a prohibition order under any law administered by the Financial Services Board or been prohibited by other regulatory bodies from operating in the financial services industry?

Y / N

If the answer is “Yes”, provide detail:

6.2.4.Have you been involved with a corporation, which has been censured, disciplined, suspended or refused membership or registration by a stock exchange, future exchange, other market or regulatory authority?

Y / N

If the answer is “Yes”, provide detail:

6.2.5.Have you had any judgment (including a finding of fraud, misrepresentation or dishonesty) given against youin any civil proceedings, in South Africa or elsewhere or arethere any proceedings now pending which may lead to such judgment?

Y / N

If the answer is “Yes”, provide detail:

6.2.6.Have you knowingly or negligently aided or abetted other Personsin the breaching of any laws, regulations, exchange rules or codes of conduct?

Y / N

If the answer is “Yes”, provide detail:

6.2.7.Have you, or has any body corporate, partnership, trust or unincorporated body with which you are, or have been associated as a director or member of the managing executive, been the subject of any investigation or disciplinary proceedings by any regulatory authority (whether in the Republic or elsewhere) or exchange, professional body or government body or agency?

Y / N

If the answer is “Yes”, provide detail:

6.2.8.Have you ever been declared insolvent (either provisionally or finally) by a court in the Republic or elsewhere or has a bankruptcy petition ever been served on you?

Y / N

If the answer is “Yes”, provide detail:

6.2.9.Have you ever been refused a licence or registration in any place under any law, which requires licensing or registration in relation to securities, properties or participationbonds activities?

Y / N

If the answer is “Yes”, provide detail:

6.2.10.Have you ever been refused authorisation to carry On Businessby any regulatory body (whether in the Republic or elsewhere), or has such authorisation ever been suspended or revoked by any such body, because of negligence, incompetence or mismanagement?

Y / N

If the answer is “Yes”, provide detail:

6.2.11.Have you, in the Republic or elsewhere, been censured, disciplined, warned as to future conduct, or made the subject of a court order at the instigation of any regulatory authority or any professional body to which you belong or belonged, or have you everheld a practising certificate subject to conditions?

Y / N

If the answer is “Yes”, provide detail:

6.2.12.Have you, in the Republic or elsewhere, been dismissed from any office or employment, or been subject to disciplinary proceedings by your employer or barred from entry to any profession or occupation?

Y / N

If the answer is “Yes”, provide detail:

6.2.13.Have you failed to satisfy any debt adjudged due and payable by you, as a judgment-debtor under an order of a court in the Republic or elsewhere, or made any compromise arrangement with your creditor within the previous 10 years?

Y / N

If the answer is “Yes”, provide detail:

6.2.14.Has any body corporate, partnership, trust or unincorporated institution with which you were associated as a director or member of the executive,in the Republic or elsewhere, been wound up, made subject to an administration order (including curatorshipand judicial management), otherwise made any compromise or arrangement with its creditors or ceasedtrading either while you were associated with it or within one year after you ceased to be associated with it or has anything analogous to any of these events occurred under the laws of any other jurisdiction?

Y / N

If the answer is “Yes”, provide detail:

6.2.15.Have you been concerned with the management or Conductof the affairs of any body corporate which, by reason of anymatter relating to a time when you were so concerned, hasbeen censured, warned as to future conduct, disciplined or made the subject of a court order at the instigation of any regulatory authority in the Republic or elsewhere?

Y / N

If the answer is “Yes”, provide detail:

6.2.16.Are you presently, or do you, other than in a professional capacity, expect to be engaged in any litigation in the Republic or elsewhere?

Y / N

If the answer is “Yes”, provide detail:

6.2.17.Do you have any further information which should be brought to the registrar’s attention, which may have an impact on the evaluation by the registrar of your honesty and integrity?

Y / N

If the answer is “Yes”, provide detail:

  1. Shareholding in the manager by an Individual Proposing to Become a Director.

7.1Are shares in the manager registered in your name or the nameof a related person?

Y / N

If the answer is “Yes”, furnish the name(s) in which it is registered, number and class of shares:

7.2.In how many shares in the manager (not being registered inyour name or that of an associate), do you or the related person have a beneficial interest?

7.3.Do you, or does any related person, hold shares in the manager as trustee or nominee?

Y / N

If the answer is “Yes”, provide detail:

Y / N

7.4.Are any of the shares in the manager mentioned in replyto questions 7.1, 7.2 and 7.3 pledged to any person or entity?

If the answer is “Yes”, provide detail:

7.5.What proportion of the voting power at any general meeting of the manager (or of another body corporate of which it is a subsidiary) are you or any related persons entitled to exercise or control the exercise of?

7.6.If the exercise of the voting power at any general meeting of the manager or of another body corporate of which it is a subsidiary, is or may be controlled by one or more related persons of you, furnish the proportion of the voting power so controlled in each case and the identity of each related person:

  1. Is there any other information or documents that are relevant to this document?

Y / N

If the answer is “Yes” kindly specify the information or documents.

  1. COMPETENCE

Licencesand OtherAuthorisations

Listanylicences,registrations,authorisationsorequivalentapprovals(whereheldpersonallyorasarepresentative),professionalqualificationsandmembershipsheld at anytimein the previous10years:

Licences,registrations,etc. / Dates(mm/yy)

ProfessionalQualificationsandMemberships

Details / Date(mm/yy) / NameofProfessional Body

OtherRelevantExperience

Pleaseprovideanyadditionalinformationaboutyourareasofexpertiseand/orexperiencethatdemonstratesyourcompetencetofulfillthepositionorroleyouwill beassumingor haveassumed.

NOTE:Ifmorespaceisneededtheanswersshouldbewrittenonaseparatesignedanddatedsheetofpaperand referenced to thisquestion.

  1. Declaration Consent

IconfirmthattheinformationsuppliediscompleteandcorrecttothebestofmyknowledgeandbeliefatthetimeofsubmissionandthattherearenootherfactsmaterialtotheapplicationortheassessmentofmyfitnessandproprietytocarryoutdutiesofwhichtheFSBshouldbeaware.

IundertaketoinformtheFSBwithoutdelay,ofanymaterialchangestotheinformationsupplied in thisformbycompletingandsubmittingaPersonalDeclaration form.

IunderstandandacceptthattheFSBmaywishtomakeenquiries–bothnowandonacontinuingbasis–tosatisfyitselfastomyinitialandcontinuingfitnessandpropriety.Iunderstandthattheseenquiries willbeinrelationtotheinformationIhaveprovidedin thisformandinrelationtomyfitnessandpropriety,ingeneral.Iacknowledgethatthismayincludeverificationofanypastcriminalconvictions,recordsmaintainedbyotherregulatorsoutsideoftheRepublic of South AfricaconcerningmyselforanyregulatedentitywithwhichIhavehadpreviousinvolvement,educationand employment information,qualificationsobtained,court recordsconcerning disqualifications andinsolvencyproceedings–including companyregistriesoutsideofthe Republic of South Africa.

Accordingly,Iauthoriseanyperson,bodyorinstitutionnamedinthisForm,togetherwithanyperson,bodyorinstitutionthattheFSB mayapproach,toprovidesuchinformationastheFSBisoftheviewmayberelevanttoitsassessmentofmyinitialandongoingfitnessandpropriety.

IalsoauthorisetheFSBtodisclosetoanylicenseapplicantorlicensedbusiness,inconnection withwhich Imaybeassessed,information that the FSB believesmayberelevanttothe assessmentofmyinitialand ongoing fitnessand propriety.

IconfirmthatIfullyunderstandmyrole(s)andresponsibilitiesundertheLaw(s) and Regulationstowhichthisquestionnaire relates.

Signed:
Date:
Name(blockletters):
  1. DOCUMENTS TO BE SUBMITTED

Pleasetickbeside each ofthe itemsbelow:

Documents to be Enclosed by Directors / Proposed Directors

LIST OF DOCUMENTS / Ref. / Attached
1 / A certified copy of the RSA identity number
2 / Completed Personal Credential Verification Forms (Available on the FSB website)
3 / Curriculum vitae
4 / Police clearance certificate
5 / Certified copies of Professional Qualifications Certificates
6 / The other documents, if any, mentioned in questions in support of the information contained in this document. (Please indicate the pages of each enclosure and the number of question above to which enclosure relates).

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